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S A N J O A Q U I Environmental Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any bAIFlOI 0alttiors noted In the'Wice In Comply'In thu rlllaGired Inapo0an Report mint bo cgrrpe&W 1 011 34 darif of <br /> ramgX of this irspertiW- This cwmiOeErw form must be subm Irlad to iris EnvhonMf ref fi$aflh I rrlrD7r W(EMD)addaxes al <br /> the battdrrt of this form within 30 days of rerA�lpt cf ttia Inspeclion Roporl- HSC 25404_t.4r..X 11) <br /> M Qxmgfigm to gVwr 'k41.R1_1on noled In 11w attached Ins lion Raped�R)or Cnniinurllion Farm.or disputn ro any <br /> violatkma,arc to be submi"ad using tNs car0cntion arrd nit imed to ERB 2 Litt m�uniess otherwise PIrmc fled in The <br /> InSpedlon Fe 11. HSO 251M(d(3) <br /> Note: All E H D staff time associated with falling to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, Jhrti operator Dl the sine mtr91 include. <br /> A slelemanl documeming what oxsectiva ac§Drvs wore taken rx wil beh taken kx each viadalron <br /> CapW Of Sample resultsFinarrilesrsltraining r rxfStnlher appropriate paperwork.andlor photos verK)dng cc mx[Ions <br /> OPefatnr -cordfNUMM <br /> lrtspecbno D81e: Dclober 02, 2024 Inspected By: ALBERTO FERNANDEZ <br /> Facility Address: 1941 E LOCKHEED GT, 8TOTIKTON CERS 113; 10/81291 <br /> I cerWy under penally of law that; <br /> 1. 1 have carrucW!tho violataans specified in the Insprkdron Rapart from the above-meniianeG Inspection dale. <br /> 2 I have personaly examined the€ollawtng documentation submitted as proof of canrpfianee FiOR EACH VIOLATION <br /> and I believa lh6 Narmalion to be",aGP-UT;3te,and r.Orrrplela'. <br /> Pharos Paperwork Staterrmr,l <br /> 3, 1 am aulhadzed to submit this rerlificatiw on tjvIr1 if of the Despondent_ <br /> 4, 1 am aware that there are slrgninceni penallies for wbrn tang Use inforroalion,including the pc3sibitity of d firm arFdlor <br /> Imprisonment Few knovm viol-Ahom. (HSC 25491) <br /> Name: I r,j o-z r,:sa— Trite:_ <br /> Signature; Date_ '? <br />